Barbara Harrington

Performance Assessment and Wicked Problems: The Case of Health Inequalities:

This article considers the background to one of the projects in the UK Economic and Social Research Councils Public Services Programme: a major; three-year investigation of how health inequalities are being framed for intervention at a local level in post-devolution England, Scotland and Wales. A particular interest is in the difference that performance assessment makes as it engages to a greater or lesser extent with health inequalities.

Keeping warm and staying well. Does home energy efficiency mediate the relationship between socio-economic status and the risk of poorer health?

This paper discusses the findings of two surveys, undertaken in 2000 and 2001, which investigated relationships between home energy efficiency, socio-economic status and respondent health. Data were collected through interviews with an informant from each household and energy surveys. Respondents were drawn from relatively poor households. The main health measure used in the analysis, respondent-assessed overall health, was statistically significantly related to other health indicators, including SF36 scores, the reported presence of limiting conditions and health care behaviours such as visiting the GP. Worse respondent self-assessed health was statistically significantly related to occupational, wealth and income measures of poorer socio-economic status. However, measures of heating satisfaction and sense of mastery displaced the socio-economic measures when they were included in the predictive logistic regression model for self-assessed respondent health. Objective home energy efficiency, measured by SAP ratings, was associated with health in the model independently of the subjective measure. The findings support other evidence that home energy efficiency makes an important contribution to the relationship between lower socio-economic status and poorer health, and document the combined relationship between objective and subjectively measured home energy efficiency and health.

Business Process Re-engineering in the Public Sector: a Case Study of the Contributions Agency

There has been a growing literature which, from a social science perspective, seeks to critically assess the use of business process re-engineering (BPR) in effecting radical organisational change. Using a case study of the Contributions Agency, this article reports on the problems of using BPR in a public sector organisation, and discusses the findings in relation to the current critique of BPR.

Wicked Comparisons: Reflections on Cross-national Research about Health Inequalities in the UK

This article discusses a comparative study of how local actors tackle health inequalities in England, Scotland and Wales. The main method used in this study was a thematic analysis of 200 interview transcripts. Its focus was on how health inequalities are framed for intervention by performance assessment systems and the challenge for these systems that their nature as a ‘wicked issue’ presents. The three different national contexts are described, including organizational structures and the use of targets, and the difficulty of making evaluative comparisons is considered. Reflecting on results from the study, it is concluded that both divergence and convergence in themes across the three countries reveal narrative patterns that draw on discourses rather than evidence. The nature of national performance audit regimes appears to play an important part in shaping these discourses, which are themselves evolving, partly in interaction with local feedback.

Health inequalities in England, Scotland and Wales: Stakeholders' accounts and policy compared

OBJECTIVES The election of a Labour government in 1997 brought the issue of health inequalities firmly back on to the policy agenda across the UK. Since then, in the wake of devolution, the need to tackle health inequalities has been highlighted as a policy priority in all three mainland UK countries, albeit with varying degrees of emphasis. This paper reports on a major cross-national study, funded by the Economic and Social Research Council, investigating how National Health Service bodies, local councils and partnerships make sense of their work on health inequalities, and examining the difference made by the contrasting approaches that have been taken to performance assessment in England, Wales and Scotland. STUDY DESIGN Case studies, semi-structured interviews and analysis of key policy statements. METHODS In order to explore how health inequalities have been approached by the three governments (noting that there was a change in governments in Wales and Scotland during this time), key policy statements published between May 1997 and May 2007 were analysed. Concurrently, data from stakeholder interviews carried out in 2006 in case study areas in each country were analysed to determine the extent of alignment between policy and practice at local level. RESULTS This paper suggests that claims about the extent of health policy divergence in post-devolution Britain may have been exaggerated. It finds that, whilst the three countries have taken differing approaches to performance assessment and the setting of targets, policy approaches to health inequalities up until 2007 appear to have been remarkably similar. Furthermore, the first round of interview data suggest that variations in local understandings of, and responses to, health inequalities cannot always be clearly distinguished along national lines. CONCLUSIONS Based on the policy analysis, devolution in the UK does not appear to have resulted in substantively different national policy approaches to health inequalities. Indeed, the overall analysis suggests that (prior to the 2007 elections in Scotland and Wales) the differences between local areas within countries may be of as much interest as those between countries.

Framing health inequalities for local intervention: comparative case studies

This article explores how health inequalities are constructed as an object for policy intervention by considering four framings: politics, audit, evidence and treatment. A thematic analysis of 197 interviews conducted with local managers in England, Scotland and Wales is used to explore how these framings emerge from local narratives. The three different national policy regimes create contrasting contexts, especially regarding the different degrees of emphasis in these regimes on audit and performance management. We find that politics dominates how health inequalities are framed for intervention, affecting their prioritisation in practice and how audit, evidence and treatment are described as deployed in local strategies.

A Randomised Controlled Trial of an Energy Efficiency Intervention for Families Living in Fuel Poverty

This paper discusses a pragmatic randomised controlled trial of a fuel poverty intervention undertaken in NE England over a four-year period, starting in 2000/2001. Home energy efficiency was measured through Standardised Assessment Procedure (SAP) ratings in each year of the trial. The trial group received an energy efficiency intervention package in year three, and the control group in year four. Year three room temperature data for a sub-sample of 100 households were obtained. A comparison group of households not living in fuel poverty were also surveyed in all four years of the study. The intervention improved SAP ratings by 12 points, generating room temperature increases of about one degree Celsius. Families did not respond to energy efficiency gains by reducing their heating expenditure. The intervention generated improvements in satisfaction with household warmth. Its receipt was not associated with gains in self-reported health. However, modest correlations between room temperatures and better social functioning, as measured by the SF36, was found.

Flexible and personalised? An evaluation of a UK tailored employment support programme for jobseekers with enduring mental health problems and learning difficulties

The employment position of people with enduring mental health issues and learning difficulties (intellectual impairment) is a major policy and moral challenge. The continued exclusion from paid work for those disabled people who are otherwise keen to work is marked in Western Europe even in high per capita welfare states. The paradox here is that disabled people have received policy and programme attention, but arguably programmes have become increasingly ‘corporeal’ and medicalized. Condition management programmes (CMPs) epitomize this approach and focus on getting the sick and disabled body/brain more work-ready ahead of wider supports. By way of contrast this article presents the results of a large-scale evaluation of a non-medicalized approach in the UK which concentrated on careful job matching, intensive support and barrier reduction. It argues that flexible personalized approaches will afford greater employment success than a focus on deficits and welfare dependency reduction.

Older people’s views and experiences of engagement in standardised patient simulation

Background The last two decades have witnessed initiatives aimed at improving the care of older people, including educating nurses so that they are equipped with the skills to care for older people with frailty and complex multimorbidities. It has been suggested that involvement of older service users in nurse education can facilitate the development of nurses’ caring skills by promoting understanding of the reality of older people’s situations. One method of involving older service users is standardised patient simulation (SPS). While some recent studies have acknowledged the importance of considering standardised patients’ experiences and perceptions of simulation, to date few have focused specifically on the experiences of older people. Methods In this qualitative study, data were collected via focus groups, whereby older people were invited to discuss their views and experiences of involvement in SPS. Data were analysed using open coding. Findings Four themes emerged from the data, demonstrating that involving older people in SPS may be beneficial for their well-being. The four themes were: ‘using personal experiences to improve care’, ‘having a sense of purpose’, ‘preparation and support for SPS’ and ‘feeling appreciated’. Discussion While most participants reported that they enjoyed the SPS activities, engagement appeared to have had a much deeper significance for them. Many participants’ responses suggested that involvement assisted them to ‘make sense’ of their experiences of illness and healthcare, and also gave a sense of purpose, of belonging and of being valued. Conclusion Findings support the need for nurse educators to consider developing SPS programmes that involve older people.